Forms
VFC Southeast (B) Region Temperature Log Form
Immunization - Form
June 5, 2025
Eddy, Lea, Lincoln, and Roosevelt
VFC Southwest Region Temperature Log Form
Immunization - Form
June 5, 2025
Catron, Dona Ana, Grant, Hidalgo, Luna, Otero, Sierra, and Socorro
Certificate of Exemption from Immunization (English)
Immunization - Form
April 4, 2025
This form may be used by individuals requesting a religious or medical exemption to immunization for their children whom attend any public, private or parochial pre-school, kindergarten, elementary, secondary school, or home school and for children attending daycare of childcare facilities.
Certificate of Exemption from Immunization (Spanish)
Immunization - Form
April 4, 2025
This form may be used by individuals requesting a religious or medical exemption to immunization for their children whom attend any public, private or parochial pre-school, kindergarten, elementary, secondary school, or home school and for children attending daycare of childcare facilities.
NMSIIS Organization Security and Confidentiality Agreement 2025
Immunization - Form
May 22, 2024
Participant organization security and confidentiality agreement for the New Mexico Statewide Immunization Information System.
NMSIIS User Security and Confidentiality Agreement 2025
Immunization - Form
May 22, 2024
NMSIIS User Security and Confidentiality Agreement 2024
VFC Provider Staff Change of Contact and uploading Training
Immunization - Form
April 13, 2023
VFC Provider Staff Change of Contact and uploading Training
VFC Physician Signing Agreement Change of Contact
Immunization - Form
April 13, 2023
VFC Physician Signing Agreement Change of Contact
NMSIIS Organization Security and Confidentiality Agreement 2023
Immunization - Form
January 3, 2023
Participant organization security and confidentiality agreement for the New Mexico Statewide Immunization Information System.
NMSIIS User Security and Confidentiality Agreement 2023
Immunization - Form
January 3, 2023
NMSIIS User Security and Confidentiality Agreement 2023
COVID-19 Vaccine Troubleshooting Report
Immunization - Form
August 24, 2022
COVID-19 Vaccine Troubleshooting Report
VFC School Immunization Consent Form
Immunization - Form
August 17, 2022
This is the form to be completed by parents or guardians indicating whether or not a child is to be vaccinated at school.
VFC Vaccine Administration Form (Part B)
Immunization - Form
August 17, 2022
This form allows you to provide immunization information for entry into NMSIIS.
CDC-Revised document as COVID-19 Vaccine Program Provider Agreement
Immunization - Form
May 18, 2022
CDC-Revised document as COVID-19 Vaccine Program Provider Agreement
CDC-Supplemental document as COVID-19 Vaccine Redistribution Agreement
Immunization - Form
May 18, 2022
CDC-Supplemental document as COVID-19 Vaccine Redistribution Agreement
NMSIIS Decision to Remove Record
Immunization - Form
December 30, 2021
This form is used by a patient/parent/legal guardian to remove records from the New Mexico Statewide Immunization Information System.
NMSIIS Decline to Participate Form
Immunization - Form
December 30, 2021
This form is used by a patient/parent/legal guardian to decline to participate in the New Mexico Statewide Immunization Information System.
Adult Vaccine Consent Form
Immunization - Form
October 1, 2021
This form may be used by adult patients aged 19 and older to provide vaccination consent to a healthcare provider.